BB is a 28-year-old female who presents to your clinic with dysuria, suprapubic heaviness, flank pain and nausea. She is running a fever of 101.2 F but is otherwise hemodynamically stable. Her urinalysis results show 3+ bacteria, WBC 425 per high power field, positive for leukocyte esterase and positive for nitrite. Her urine cultures are still pending, but she is diagnosed with a suspected UTI and will be treated as an outpatient. She has a PMH significant for hyperlipidemia, anxiety, and myasthenia gravis. She has an allergy to sulfa drugs listed on her profile (rash/hives). She is currently taking 20mg atorvastatin PO once daily, buspirone 15mg PO BID PRN, and pyridostigmine 180mg extended release tablets PO BID. This is her first UTI. Which of the following statements regarding treatment for BB are true?
a) This UTI should be classified as acute cystitis
b) The most likely pathogen causing this UTI is E. coli
c) The patient could receive Macrobid 100 mg PO BID x 5 days
d) The patient could receive Bactrim 800mg/160mg PO BID for 7 days
e) The patient could be given a dose of Rocephin 1 g IM once then started on Augmentin 875mg PO BID for 7-14 days.
Brands/Generics: Bactrim (trimethoprim-sulfamethoxazole/TMP-SMX), Macrobid (nitrofurantoin), Rocephin (ceftriaxone) , Augmentin (amoxicillin/clavulanate)
Answers with Rationale:
Answers B and E are correct.
Answer Choice A: This answer choice is false. In order to be classified as acute cystitis/lower UTI, the patient would not have any systemic symptoms. The symptoms would be localized to the bladder and include things like dysuria, urgency/frequency, suprapubic heaviness, and gross hematuria. When there are systemic symptoms such as fever, flank pain, nausea/vomiting, or altered mental status, the UTI is classified as acute pyelonephritis/upper UTI. Our patient was running a fever, had flank pain and was nauseous so she would have acute pyelonephritis not cystitis.
Answer Choice B: This answer choice is true. Typically, E. coli and other gram-negative rods present in the GI tract (S. saprophyticus, K. pneumoniae and P. mirabilis) are the types of bacteria that can reach high concentrations in the urine. If this were a complicated UTI or the patient had a recent healthcare exposure, there might be a wider spectrum of pathogens that would need to be covered (Ex: Pseudomonas aeruginosa, other Klebsiella species, Enterobacter sp, etc.).
Answer Choice C: This answer choice is false. Macrobid is used in the treatment of cystitis only because it does not reach the site of action in the kidneys for pyelonephritis. It concentrates really well in the urine and is a first line choice for lower UTIs, however it does not achieve adequate levels in the kidneys and therefore would not be used in this case of pyelonephritis.
Answer Choice D: This answer is false. The patient has a sulfa allergy making this choice incorrect.
Answer Choice E: This answer is true as this is a correct regimen for pyelonephritis. A one-time dose of a long acting parenteral antibiotic (ceftriaxone or aminoglycoside) followed by an oral beta-lactam such as Augmentin, cefdinir or cefpodoxime would be appropriate. Keep in mind that oral beta-lactams are inferior in some head-to-head trials in patients receiving bactrim or FQs. Oral bactrim would also generally be an option after one dose of ceftriaxone, but not in this patient due to the documented allergy.
A fluoroquinolone, such as ciprofloxacin or levofloxacin, would be an option as well in most patients but our patient has myasthenia gravis which is may be worsened by FQ therapy. FQs are not recommended to be given to patients with myasthenia gravis. Keep in mind that moxifloxacin (Avelox) is not appreciably renally excreted and thus not appropriate for treatment of UTIs.
Exam Competencies: Area 1 – Obtain, Interpret, or Assess Data, Medical, or Patient Information (1.5 – Signs or symptoms of medical conditions, healthy physiology, etiology of diseases, or pathophysiology), Area 2 – Identify Drug Characteristics (2.1 – Pharmacology, mechanism of action, or therapeutic class), Area 3 – Develop or Manage Treatment Plans (3.4 – Drug dosing or dosing adjustments; duration of therapy, 3.6 – Drug contraindications, allergies, or precautions, 3.10 – Drug pharmacokinetics or pharmacodynamics)
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